Craven_Well Abandonment_20241002 (25)

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WELL ABANDONMENT RECORD Far InteraI use ONLY:
r This form can be used for single or multiple wells ( '
1.Well Contractor Information:. WELL ABANDONMENT,DETAILS
Trevor Mizelle 7a.Number of wells being aabandoned: N/A
Well Contractor Name(or well owner personally abandoning well on hisAmer property) For multiple injection or non-waters Iupply ivells ONLY with the same
constnrctiordabandonment,you can sitbndt one form.
4629C
NC Well Contractor Certification Number
7b.Approximate volume ofwater remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well pennits(i.e.County,State,Variance,hjectiott,etc.)ij47tmvn 7d.Amount of disinfectant used: N/A
3.Well use(checksvell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic - ❑Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ■Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 125 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stommwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Surface Pour {{
4.Date well(s)abandoned: 9/11/2024 �,.
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5a.Well Location:
Y:V.itr.t.:�. ,•.• .;d"vim:-,-� i�ic,;
MCAS Cherry Point �,_: ri;
Facility/Owner Name Facility ID#(if applicable) 8•Certificatio�I U•{CAI G
PIT 6 MCAS Cherry Point, NC, Havelock, NC 28532 September 26.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CRAVEN By signing thisform 1 hereby certify that the mvell(s)mvas(were)abandoned in
County Parcel Identification No.(PJN) accordance with 15A NCAC 02C.0100 or 2C Well Construction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one.lat/long is sufficient) 9.Site diagram or additional well details:
34.8981209966 N 76.8882612652 ,�r You may use the back ofthis page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For nadtiple ityuction or non-water supply
well ONLYwilh the same construction obandotunent,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 100RW08 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells- In addition to sending the form to the address in
1Oa above,also submit one copy of this form within 30 days of completion
6c.Borehole diameter: 4.0 (in.) ofwell abandonment to time following:
6d.Water level below ground surface: 8.20 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 10c.For Water Suanly&Iniection Wells: In addition to sending the form
to the address(es)above,also submit one copy ofthis form within 30 days of
completion of well abandomuent to the county health department of the
6f.Inner casing/tubing length(if known): 15(ft.) county where abandoned.
6g.Screen length(if known):
P-.\2024\224001-PIE-PS-CHERRY POINT-2ND SEM 2024 1ST SEM 2025 CAMP\Prr 6 WELL ABANDONMENTTIELD1224001_GINr.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013